Live music in the intensive care unit – a beautiful experience

ABSTRACT

Background

The growing number of lightly or non-sedated patients who are critically ill means that more patients experience the noisy and stressful environment. Live music may create positive and meaningful moments.

Purpose

To explore non-sedated patients’ experiences of patient-tailored live music interventions in the intensive care unit.

Design

A qualitative study using a phenomenological-hermeneutic approach. Data were collected at two intensive care units from September 2019 to February 2020 exploring 18 live music interventions performed by music students from The Royal Academy of Music, Aarhus, Denmark.

Methods

Observations of live music interventions followed by patient interviews. All data together were analysed using Ricoeur’s theory of interpretation. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used.

Results

Five themes emerged: 1) A break from everyday life, 2) A room with beautiful sounds and emotions, 3) Too tired to participate, 4) Knowing the music makes it meaningful and 5) A calm and beautiful moment.

Conclusion

Patient-tailored live music to awake patients is both feasible and acceptable and perceived as a break from every-day life in the ICU.

Implications for practice

Supporting health and well-being by bringing a humanizing resource into the intensive care setting for patients and nurses to enjoy.

KEYWORDS:

• Intensive care unit
• music intervention
• non-sedation
• nursing
• patient experience
• phenomenology and hermeneutics

Introduction

A paradigmatic shift has occurred within intensive care nursing and treatment, resulting in a growing number of patients who are conscious during mechanical ventilation. Therefore, patients describe experiences of isolation from the outside world, altered time perception, pain, stress and meaninglessness in the unfamiliar intensive care unit (ICU) environment. In this study, live music was tested as an intervention aiming to give ICU patients an experience from the world beyond the ICU. We expect this to contribute to healing and wellbeing within this highly technological environment.

Background

The past decade a shift in using the lowest possible dose of sedatives is considered beneficial for long-term patient outcomes in the ICU (Devlin et al., 2018; Vincent et al., 2016). Previously, ICU care and treatment primarily focused on the sedated patient’s body. Today, patients are able to interact and communicate with nurses and relatives during most of their ICU stay (Laerkner et al., 2015). These changes raise new challenges in nursing care.

The ICU environment

The ICU is a very unfamiliar environment for the patients with high noise levels, bright light, alarms and unknown technology. Alarms, beeps and ringing phones are part of the soundscape in the ICU − 24 hours a day (Petrucci, 2018). Nothing can really prepare a patient for waking up in the noisy and frightening ICU environment, where everything is foggy and unfamiliar. Petrucci (2018) described that hearing seems to be the only sense still functioning, making it very important to follow a new trend in intensive care nursing; humanizing ICU (Vincent et al., 2017). In a review by leading, internationally esteemed ICU researchers, the early Comfort using Analgesia, minimal Sedatives and maximal Human care (eCASH)) strategy was described (Vincent et al., 2016). Live music may contribute to solving issues related to the unfamiliar environment by transforming it into a more familiar and domestic environment (Petrucci, 2018).

The effect of music on patient care in the ICU

For decades, music-based interventions have been used in the ICU. In 1995, a review found that music therapy effectively relieves pain and anxiety in many critical care patients (Henry, 1995). Recently, the WHO stated in a report that a major increase has been recorded in research into the effects of arts on health and well-being (Fancourt & Finn, 2019). The report also described how mechanically ventilated patients’ anxiety, heart rate, blood pressure and respiratory rate may be reduced if they are listening to pre-recorded music. Furthermore, the use of music in intensive care has been linked to improved sleep while patients are being mechanically ventilated and to lower levels of traumatic distress at discharge (Fancourt & Finn, 2019). In a recent umbrella review studying the Effectiveness of Music-Based Intervention in Improving Uncomfortable Symptoms in ICU Patients, Chen and colleagues (Chen et al., 2021) found that music decreased anxiety, pain, agitation, anaesthesia dose and sedative use and further, it reduced the risk of delirium and feelings of discomfort, and improved sleep quality. In 38 of the 41 included studies the music was recorded music played via headphones (Chen et al., 2021). In a newly randomized study live music therapy significantly reduced agitation and heart rate in adult patients receiving mechanical ventilation in the ICU (Golino et al., 2023). Also, live music therapy in a paediatric intensive care unit, has shown that live music therapy may be more effective than recorded music interventions in reducing pain and anxiety in paediatric critical care patients (Bush et al., 2021). Furthermore, studies referred to live music therapy for premature infants or newborns with significant results on heart rates, breathing rates, and paediatric patients discomfort levels (Ferro et al., 2023).

Chiasson et al. (2013) was the first to describe the effect of spontaneous harp music on individual patients in an ICU played by professional musicians. The study was performed to investigate whether live music may serve to relax ICU patients. Each consenting patient was randomly assigned to receive either a live 10-minute concert of spontaneous music played by an expert harpist or a 10-minute resting period (Chiasson et al., 2013). Results showed that spontaneous harp music significantly decreased the patients’ perception of pain by 27%, but did not significantly affect heart rate, respiratory rate, oxygen saturation, blood pressure or heart rate variability (Chiasson et al., 2013). Furthermore, the harp music was described as a wonderful experience for the ICU clinicians and patients (Chiasson et al., 2013).

In another short clinical report, it is described how young bachelor students played live music bedside, which was an additional, simple and inexpensive factor in the open ICU (Petrucci, 2018). However, physiological outcome measurements or patient experiences were not reported in another original study. In a haemodialysis clinic, playing live-music at a patient’s bedside was found to have the potential to create an autonomous space described as an intermediate world away from medical hierarchy and to establish a synthetic sound environment where patients, staff and musicians can connect and communicate nonverbally through music (Bro et al., 2022).

In the ICU context, live music remains rare and sporadic, and the study by Chiasson et al. (2013) is the only one to have investigated the effect of a live music interventions played by professional musicians. Despite limitations, the impact of the present study on the ICU environment is important. Data were collected to gain insights into live music interventions in the ICU as a basis for developing music interventions in the ICU within a new humanizing concept (Vincent et al., 2017). Because the evidence related to playing live music in the ICU remains very limited, it is important not only to study its effect and impact, but also to uncover the lived experiences of listening to live music. To counter the unfamiliar and stressful experiences that the ICU environment brings, it is necessary to study whether live music is an appropriate intervention and how music is experienced by patients. To our knowledge, no studies have previously explored the ICU patients’ experiences of a tailored live music intervention performed by bachelor and master students studying classical and contemporary music. The aim of this study is therefore, to explore non-sedated patients’ experiences of patient-tailored live music interventions performed bedside in the intensive care unit.

Material and methods

Design

The study adopted a qualitative design within a pheno-menological hermeneutic approach. A phenomeno-logical hermeneutic method emphasizes both being descriptive and interpretive. Often a phenomenological approach is described as primarily descriptive, but when combined with hermeneutics, it offers access to a deeper understanding of the lived experience (Brinkmann & Kvale, 2015). The phenomenon of live music is a new and alternative intervention in the ICU and when studying the phenomenon, we will put a special emphasis on the live part of the phenomenon. Therefore, to explore this phenomenon, an open, explorative approach was chosen where we both want to capture what is going on in the room and what the patients are experiencing. Therefore, we both used observations and interviews to collect data in an open phenomenological way where the observer and interviewer had an open approach to what happened in the room and with open-ended questions in the interview. During the data collection and analysis, our focus was not on a specific part of the live music concert, e.g., a music piece, instrument or on pain, but on gaining an overall insight into patients’ experiences of live-music interventions in the ICU. The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting the findings (Tong et al., 2007).

Live music intervention

The study was conducted in collaboration with the Royal Academy of Music, Aarhus, Denmark (RAMA). Six master- and three bachelor students, studying classical and contemporary music, underwent a standardized training programme after which they, solo or duo, offered patient tailored live music interventions to one conscious patient in the ICU at a time in a single room. The training programme included a theoretical introduction to the practice, information on the ICU patient, guidance on repertoire, ethical issues, workshops, sound test and a tour in the ICU. To develop the practice, the musicians received supervision before and after each music session, by an experienced healthcare musician, likewise the nurses informed the musicians about the patients’ reactions on the experience. The students planned a programme for each intervention day, and the patients therefore did not have the opportunity to choose specific pieces of music. The students prepared a mix of relaxing, soothing, familiar and unknown music with low-pitched instruments, e.g., guitars, cellos, vibraphone, or low-voice singing in a slow tempo (60–80 beats per minute), with a predictable musical structure, rhythm, and tonality, as it has been shown that low-pitched and low-intensity music may be calming and may regulate arousal levels (Jespersen et al., 2022; Vuust & Kringelbach, 2010). The length of the music interventions ranged from 7 to 21 minutes, with an average length of 13 minutes depending on how many music pieces the patient wanted to listen to. The canon of repertoire included a mix of classical original music (J.S. Bach, Gabriel Fauré, Francisco Tárrega, Heitor Villa-Lobos, John Dowland, Fernando Sor) to well-known Danish songs (Carl Nielsen, Thomas Laub, Sebastian), together with the musicians’ own arrangements of familiar pop/rock tunes (Elwis, Ray Charles). In order to target and personalize the music interventions to the spontaneous reactions from the patients; e.g., change in facial expression, heartbeat, verbal comments, etc., the musicians were flexible and selected suitable repertoire in the moment, varying in musical expression, interpretation and intensity (Heniks & Smilde, 2017).

Data collection

Data were collected between September 2019 and February 2020 and based on 18 live music sessions. Data collection consisted of field observations of the 18 music sessions followed by interviews with the same 18 patients. Three of the nurses in the research group participated in collecting the data and both observations and interviews was performed by the same nurse. As they were all registered nurses, had several years of ICU experience and were employed at the participating ICUs, it was possible for them to perform participant observations as described by Spradley (1980). The degree of participation varied between observations. During observations, field notes were taken, which were subsequently transcribed. An observation guide was designed guiding the observer to have focus on the room, the people and the actions in the room. Was the room light, dark, cold, hot and who was in the room and how many, were they sitting, standing or lying etc. The focus during the observations were also on the patient and the musicians playing, how did the patient react, facial and bodily expressions, verbal expressions and interaction between the patient and the musicians. An interview guide with open-ended questions was designed for the semi-structured interviews (Brinkmann & Kvale, 2015). The opening question was: “Can you describe how you experienced the live music concert?” Followed by questions like: “Can you tell a bit about how you felt before and after the music was played? How did it feel? How did it affect you?”. Interviews were recorded and transcribed verbatim. The observations were made during the music intervention, and the interviews were conducted immediately after the live music session bedside in the ICU. The observations lasted as long as the music intervention from 7–21 minutes (average on 15 min.) and the interviews from 2–11 minutes (average on 4 minutes).

Participants

The study was conducted at two multidisciplinary ICUs in a university hospital in Denmark with a total of 20 beds for adult medical and surgical patients; the annual number of admissions was approximately 1,500. The nurse—patient ratio was 1:1, and none of the patients included were physically restrained. The two participating ICUs followed national and international recommendations, aiming to achieve a no-sedation regime (DASAIM, 2014; Devlin et al., 2018) The inclusion criteria for patients were that they had to be conscious and able to provide informed consent. Thus, sedated and delirious patients were not included. Also, patients had to be able to understand and speak Danish to be included. The patients all had been admitted to the ICU for more than 48 hours and were aged over 18 with an average on 54.6 years (range 20–79 years), 9 female and 9 men, three were mechanically ventilated via tracheostomy, 12 had oxygen via nasal catheter and 3 had no respiratory treatment. They had an average ICU stay of teen days (range 2–31 days). On the morning of the music intervention day, the nurse from the research group would designate which patients could be included. Based on the inclusion criteria, the nurses in the patient team would ask their patients if they wanted to participate and all eligible patients were approached and no one declined.

Ethical considerations

Under Danish law, non-biomedical studies do not require ethical approval (The National Committee on Health Research Ethics, 2013). Leading staff at the participating ICUs consented to the project. The musicians signed a confidentiality declaration. Participants were informed about confidentiality and anonymization of their identity and told that participation was voluntary. On the intervention day, the nurse in charge gave the patient verbal and written information about the musical intervention and the purpose of the study. If willing to participate, patients signed a declaration of consent stating that they could withdraw at any time without consequences. Patients in the ICU are vulnerable and therefore the participants were selected by the nurses in the patient team with the nurse having attention on the patient’s strength and condition. The principles of the Helsinki Declaration were followed (World Medical Association Declaration of Helsinki, 2013)

Data analysis

To ensure a high level of rigour in the analysis observations and interviews were analysed as one collective body of data, and we used both interview data and observation data to substantiate the interpretation. We did that to achieving richness and adding explanations to the data set and the interpretation (Brinkmann & Kvale, 2015).

The data analysis method was inspired by Ricoeur’s theory of interpretation, which comprises a movement back and forth between explanation and comprehension to reveal the disclosed world in front of the text (Dreyer & Pedersen, 2009; Ricoeur, 1976). The interpretation was a dialectic movement between the parts and the whole of the text in a hermeneutic spiral, an example of the analysis can be seen in Table 1. The process employed to reach an in-depth understanding of the lived experience involved three steps of analysis: (1) a naïve reading, in which the reader acquires a general sense of the text as a whole; (2) a structural analysis, which is the movement from what the text says to what the text speaks about and, subsequently, the development of themes; and (3) critical analysis and discussion, where new literary perspectives are included to reach a deeper understanding of the interpreted themes (Dreyer & Pedersen, 2009). The research software NVivo 12 was used for data analysis to ensure structure in the analysis in a Ricoeurian manner, allowing us to move back and forth between the whole and parts of the data, providing transparency and rigour in the process of analysis (Dreyer & Pedersen, 2009). The first author performed the first and second stage of the analysis and discussed it with the other authors. The third stage, the findings from the structural analysis were critically analysed and discussed by all authors in light of other relevant literature, research studies and theory. Through the critical analysis and discussion, we got an in-depth understanding of the interpreted themes and this third step is integrated in the discussion section. Adopting a critical perspective in the discussion strengthened the analysis and provided new and in-depth perspectives on the patient experiences of the live music intervention in ICU (Dreyer & Pedersen, 2009).

Table 1. An example of the structural analysis.

Meaning-bearing units (What is said)	Significance-bearing units (What the text talks about)	Theme
“So, you can say this room where you mostly hear a kind of bib-bop sound, then it’s nice that something like that happens. Something more human or what should I call it, something peaceful that is not about being in a crisis, but more like a cultural thing that one has known before, which is homely or nice” (interview 11). “When the guitar play starts, the patient closes his eyes and seems completely relaxed. Occasionally, he looks at the musician’s finger play” (Note 3). “It gave me joy, and that someone did this so that I could be happy, because I really am. Then I relaxed and closed my eyes, and then I just floated into the music, it was just really incredible. I almost think it’s the best concert I’ve been to” (Interview 5). “The musicians play the first piece together and the patient looks intensely at how they play. Gets distant in the gaze and smiles. When the music piece ends, he says “really good, very beautiful” (Note 3). “I was completely at the mercy of my emotions, you might say (the patient is laughing out loud). Crying and getting a break from all the awfulness of this place. Just to hear some music and think of something else” (Interview 9).	The patients experienced the music as a break from life in the ICU; a break from all the awful and unpleasant things that occurred in the ICU. For instance, patients heard many unknown sounds from alarms and equipment and found that it was difficult to calm down, rest and sleep. When the musicians played, the musical experience was described as nice, human and homely, a moment of calm, providing relaxation and leaving them with a positive experience. During the observations, it was very clear that the patients enjoyed the music, which seemed relaxing, soothing and positive to them. Their heart rate dropped and they got a dreamy look and closed their eyes in a relaxed state. The patients were also very preoccupied with the musicians, how they played and mastered their instrument. The patients described how they were happy and overwhelmed that the musicians would come and play just for them. They would not forget that amazing experience of floating into the music and being happy. The patients described the music experience as very intense and beautiful, where they dreamed away into the music and thought of something homely and nice, even though, at the same time, they wanted to see and experience the musicians playing. The experience was very intense and at the same time liberating. It gave the patients the opportunity to cry a little, dream away and think about something else than all the terrible things that occurred in the ICU. One patient described this as being at the mercy of his emotions. The patients had a break from everyday life being happy and relaxed floating into the music.	A break from everyday life

Results

During the structural analysis, five themes emerged. An overall comprehensive understanding of the five themes is narrated in one first-person-narrated story capturing the experiences of live music interventions, see Table 2.

Table 2. Overall comprehensive narration—a beautiful musical gift.

There are all sorts of sounds coming from inside the room next to me. I hear them quite clearly, loud beeping sounds and voices talking, but I cannot discern what they are talking about. Everything is so unfamiliar, and I am a bit scared. Then two young people came into the room and they wanted to play for me. Just imagine, to play just for me. They were just amazing; you can’t imagine how wonderful a sound they could make. I closed my eyes and it sounded absolutely wonderful. I felt completely relaxed in my whole body, it was really a pleasure to listen to. I felt like I had been given a gift, a musical gift. Yes, actually, I was completely moved and started crying and everything, but those were tears of joy. You know when someone sings so beautifully, you start to get chills, and the feeling kind of flushes down your body. It is a really wonderful experience and completely different from all the many unpleasant feelings and things in my body that I have experienced here on the intensive care unit, so it is really nice to feel something in my body that feels nice. It’s really pleasant and if it’s a piece I know it brings back memories—pleasant memories from my life. It’s incredibly beautiful, but I’m also very tired and maybe I will only stay focused for 2 music pieces. But the music brings joy and I close my eyes, and swim away into the music, I almost think it’s the best concert I’ve ever been to.

A break from everyday life in the ICU

The patients experienced the music as a break from life in the ICU; a break from all the awful and unpleasant things that occurred in the ICU. For instance, patients heard many unknown sounds from alarms and equipment and found that it was difficult to calm down, rest and sleep. When the musicians played, the musical experience was described as nice, human and homely, a moment of calm, providing relaxation and leaving them with a positive experience. One patient described this as follows:

So, you can say this room where you mostly hear a kind of bib-bop sound, then it’s nice that something like that happens. Something more human or what should I call it, something peaceful that is not about being in a crisis, but more like a cultural thing that one has known before, which is homely or nice. (interview 11)

During the observations, it was very clear that the patients enjoyed the music, which seemed relaxing, soothing and positive to them. Their heart rate dropped and they got a dreamy look and closed their eyes in a relaxed state: “When the guitar play starts, the patient closes his eyes and seems completely relaxed. Occasionally, he looks at the musician’s finger play” (observation 3). The patients were also very preoccupied with the musicians, how they played and mastered their instrument. The patients described how they were happy and overwhelmed that the musicians would come and play just for them. They would not forget that amazing experience of floating into the music and being happy. One patient described this as follows:

It gave me joy, and that someone did this so that I could be happy, because I really am. Then I relaxed and closed my eyes, and then I just floated into the music, it was just really incredible. I almost think it’s the best concert I’ve been to. (interview 5)

The patients described the music experience as very intense and beautiful, where they dreamed away into the music and thought of something homely and nice, even though, at the same time, they wanted to see and experience the musicians playing: “The musicians play the first piece together and the patient looks intensely at how they play. Gets distant in the gaze and smiles. When the music piece ends, he says “really good, very beautiful” (observation 3). The experience was very intense and at the same time liberating. It gave the patients the opportunity to cry a little, dream away and think about something else than all the terrible things that occurred in the ICU. One patient described this as being at the mercy of his emotions: “I was completely at the mercy of my emotions, you might say (the patient is laughing out loud). Crying and getting a break from all the awfulness of this place. Just to hear some music and think of something else” (interview 9). The patients had a break from everyday life being happy and relaxed floating into the music.

A room with beautiful sounds and emotions

That the music was a “live” performance where real people performed for the patients was described as incredible. Quickly, a good mood filled the room, and patients gave in to the music with their whole body, and they tried to follow the rhythm of the music: “the patient moves her head to the rhythm of the music. Follows the musician’s hand and bow as she strokes across her instrument” (observation 1). The movements of the musicians were intensely followed by the patients who at the same time immersed themselves in the music and moved in step with the beat and rhythm of the music, for example with their feet, head or whole body. During an observation, the following was observed: “The patient sighs deeply, tilts her feet, closes her eyes and moves her head in step with the music. When the piece ends, she claps” (observation 11). During a guitar piece, the musician and the patient came into such close bodily contact that the musician could follow the patient’s breathing frequency or “beat:

The musician is very concentrated on the music and the patient at the same time, and it both sounds and looks like the musician follows the patient’s breathing rhythm. Suddenly, the patient falls asleep with his head nodding forwards (the nurse subsequently describes how the patient has not slept for several days). (observation 7)

In addition to a bodily experience, the music always created a good mood in the room as the room was saturated by beautiful sounds and impressions, and patients were both affected and touched. During an observation, the following occurred:

The musicians play one last song, and the patient is touched and cry a little. When the piece concludes, the patient says:‘ so nice to see you, to see that you look like you are enjoying it - you are cool, wildly cool and so precise. Yes, I am completely touched’. The patient cries a little and one of the musicians also cries a little when she leaves the room. (observation 9)

That both the musicians and the patients were touched and cried a little was described as a beautiful and human touch. An incredible experience that just occurred without the patients being able to explain from where the emotions came. One patient described it as follows:

Yes, I was completely touched and started to cry (is laughing). Yes. Yes. Moreover, everything but yes, it’s nice. Do you know when people sing so beautifully, you get gooseflesh? Yes. Where that feeling kind of washes down across your body. It was wildly nice. Otherwise, I have had so many unpleasant feelings in my body and all sorts of things, so it’s nice to sense something that feels nice (interview 9)

The patients were very ill when they were in intensive care, and perhaps that was what made the experience more intense and incredible. For instance, the music was described as speaking to their emotions: “It was an incredible experience and it became even more incredible to lie here in these surroundings and be so ill. It touched me, it did. It spoke a lot to my feelings” (Interview 5). Being in a crisis in the ICU was also described as a heartrending situation that made the experience even stronger in a good sense. A really good experience. One patient described this as follows:

I experienced it as very touching because I am in a vulnerable situation, you could say crisis. Therefore, it became even stronger, I think. However, I think, it was really nice and I think they had a good attitude or what to call it, a good performance. They did not push themselves they were peaceful people or what to say, so I think it was a really good experience …… “I was just about to cry when they started up because I love music, so in that way it does not matter that you sometimes cry or feel touched or affected, that is human”. (interview 11)

Too tired to participate

The patients experienced that the music was very beautiful, contrasting with the hectic and noisy environment in the ICU. The ICU is described as a place that never offered them peace: “there are always terrible sounds in such a place and never peace” (interview 15). The music was described as a beautiful and very different experience than, e.g., watching TV or listening to the radio: “Totally different, completely different than watching TV, it was good” (interview 6), and therefore “time also passes in a different way” (interview 2).

Although the patients rejoiced, and it was nice perhaps to get up to sit in a chair and watch and hear the music, it was also an activity that required much of the patients, physically and emotionally. During an observation, the musicians asked if they should play a bit more and the patient replied, “I think we stop here—I am very tired, I think it was very beautiful” (observation 16). Thus, the patient could also get tired and exhausted during the music session and lack the strength to hear more than one or two musical pieces, even though it was very beautiful and nice experience. In the observation above, the patient made the following comment during the interview: “yes but after two music pieces, I was tired” (interview 16). Some patients were so ill that they would say no to the music; one patient described this as follows: “it depends a bit on how I feel, last Friday I was so ill that I said no” (interview 16).

However, some patients also got tired during the music sessions, and they were therefore too tired to share their experience immediately after during the interview. One patient noted that: “Yeah okay, it’s a little hard just to concentrate right now” (interview 12). The patients described that they never experienced peace in the ICU. Constantly, events would occur that were given priority and which related to illness and recovery, and this would limit the patients’ strength to listen to the live music and, perhaps in particular, it would rob them of the extra energy needed for the subsequent interview. Subsequently, there were many things to relate to for the critically ill patients, and therefore it could be difficult for them to relate to the experience after listening to and enjoying the music:

No, I can’t do that. No. Because there are so many things going on in my head right now that I do not think I can say anything right now. It may well be that some deeper thoughts about other things are a little pushed away right now. No, I cannot. The timing is wrong. (interview 13)

Knowing the music makes it meaningful

Often the repertoire was comprised by pieces that the patients knew and could relate to. It might be a piece that the patient liked or had heard before and therefore connected to some previous event. The patients enjoyed the music, especially it brought forward pleasant memories. One patient described it as follows:

I knew one of the pieces and it was pleasant for me, so I got better from it, I would say ……. because I could connect it to another pleasant memory that was something familiar to me. It was nice that I knew one of the pieces. (interview 1)

The music could bring out memories that felt nice. A well-known piece could also make the patient think of something else: “It is a very well-known piece of music …. I have a niece who plays the piano, including that piece; therefore, I know that piece of music in detail” (interview 13).

The session acquired a very special meaning if the piece was, e.g., a song that the patient himself had sung or could sing along with: “it was the Christmas song that I myself sing every year. It brought back memories, it certainly did” (interview 5). During the observation, it was clear that the patient sang along, and evident how important it was to have a mutual frame of reference for the song, for both the patient and the musicians:

They sing a Christmas song - the patient sings along and claps. The patient tells about travels to Greenland and the Faroe Islands where she has just sung that song. The musicians talk about the song and the patient looks intensely at the musicians and talks about the song. Both the patient and the musicians are touched by the close relationship the patient has with the song. (observation 5)

In the context of the music, a bond could arise between the patient and the musicians, e.g., because they were playing or singing the same music. It could also be a movie that created images or thoughts about something nice. A patient mentioned music from a favourite movie: “Claps again when the music is over and says: ‘That is a piece from my favourite movie’” (observation 1).

A calm and beautiful moment

That the music was played live and was performed by one or two musicians’ bedside—a solo experience for the patient and any relatives—was of great importance to the patients because it afforded an intimacy and closeness that made the experience exceptional. The patient and the musicians shared a moment during which the music tied them together, which the patients described as absolutely wonderful. They greatly appreciated that someone would do that for them. One patient described this as follows:

I think they are both good, and I also think it’s great that they bother to go around and play for someone like us. Thanks for wanting to play for me. I think it’s great that he would play a piece for me that he himself had composed. This is because I could feel that there was a connection. (interview 17)

It was a very special experience for the patients, and the fact that the musicians were skilled performers made sense to the patients: “It was a very nice sound, too, and then he played some incredible guitar, too” (interview 11) and “it also sounds good, damn good” (interview 3). During observations, one patient spontaneously exclaimed: “it’s amazing how you can make such a beautiful sound” (observation 8) and during the second music paragraph, the patient closed her eyes again and when it ended she exclaimed, “it sounds wonderful” (observation 12).

Patients expressed both enthusiasm for the musicians’ talent and watched dreamy the musicians’ skills on their instrument, e.g., when a guitarist exhibited an absolutely formidable finger play: “the next piece was a solo piece with guitar. The patient looked a little dreamy at the fingertip”(observation 3). In an interview, one patient was very fascinated by the musicians´ skills: “I just think it was fascinating to see and follow their hands, and see how they controlled their instruments, and enjoyed how good it sounded” (interview 3).

It was both “really relaxing and a pleasure to listen to” (interview 8), and the patients felt “that it was actually an extra gift” they received (interview 5). It was a musical gift and patients considered significant that it was played by live musicians; one patient described this as follows: “It means a lot with music. It is true enough it is not so often it’s live, but it happens then” (interview 16). Such a small intimate music session made much sense to the patients and they described it as both meaningful, beautiful and wonderful, being played by very talented young people. So, the patients had the opportunity to leave behind all the illness and experience of hospitalization; one patient described this as follows: “Yes, it was meaningful for me to have such a moment, to get away from all that hospitalization” (interview 11).

Discussion

Our findings show that patient-tailored live music was experienced as a break from everyday life in the ICU characterized by the awful and unpleasant things that occur when patients are critically ill. In the ICU there is many unknown sounds and noises from alarms and equipment, and patients have a difficult time calming down, resting and sleeping. When the musicians played, the experience was described as nice, human and homely, a moment of calm, providing relaxation and leaving positive impressions. In an umbrella review from 2021, the authors focused on the effectiveness of music-based interventions in improving uncomfortable symptoms among ICU patients (Chen et al., 2021). The positive results included decreased anxiety, decreased pain, decreased agitation, decreased anaesthesia dose and sedative use, decreased likelihood of delirium, decreased feelings of discomfort and improved sleep quality (Chen et al., 2021). Even though the music interventions were not live and the investigators did not explore patients’ experience but the effectiveness of the intervention, it is notable that feelings of un-comfort decreased which is in line with our findings of relaxation and positive impressions. We will argue, that we contribute to the existing knowledge with an in-depth understanding of the importance of live music in ICU with high artistic quality. If we then turn to a live music intervention in Italy by Petrucci (2018) the music from the flutes, guitars, cellos and clarinets played by the students was described as a welcome and heartening grace, which is comparable to our results of live music being perceived as nice, human and homely. Our findings of humanization and homeliness were also described in Fallek et al. (2020), where a patient described how the music allowed him to feel as if he was back home. Before the music session, the patient in question had no hope and wanted to give up, but the music made him feel as if he had another day, and he said that he would remember this day forever (Fallek et al., 2020). Seemingly, live music may be the answer to humanizing the ICU environment.

We know that the ICU environment has a stressful effect on patients, and a white paper summarized that there is good evidence that music has a positive effect by reducing stress and anxiety; modulating heart rate, blood pressure and respiration; and by reducing cortisol levels in people of all ages and in different settings (Jespersen et al., 2022). However, we do not know much about live music in the ICU setting. Thus, our findings where the experience was described as bodily is very important in regard to stress reduction. In our study, we found that the live music intervention was described as incredible; a bodily experience during which the music always established a good sense or feeling in the room, saturated by beautiful sounds and impressions. Spontaneously, it makes everyone in the room experience goosebumps, and musicians and patients would occasionally be so touched that they cried a little because the experience was so beautiful and human. When asked, this just occurred and it was difficult for them to explain from where the emotions came. This is in line with the findings in the study by Fallek et al. (2020), where a wife and daughter started crying when a music therapist started playing Fly Me to the Moon. When asked, they simply stated that the tears were tears of joy (Fallek et al., 2020). In the white paper by Gebauer and Vuust (2014), they described music as one of the seven mechanisms creating strong emotions: “Emotional contagion that is mirroring the emotional expression of music” (p. 12.) In our study, the music was experienced as something very beautiful, which contrasted with the hectic and noisy environment in the ICU. In a randomized pilot trial by Khan et al. (2020) aiming to test if personalized music and slow-tempo music using headphones would decrease delirium in ICU patients, 90% of the patients commented that music made them feel normal and calm (Khan et al., 2020). Even though the intervention had no significant effect on delirium due to a small sample size, the study enjoyed a high acceptability and meaningfulness in the patients’ experiences, which underpins that music is a promising intervention also in the ICU (Khan et al., 2020).

Some of the patients in our study were too tired to participate or experienced fatigue during the music session and therefore did not have the strength to listen to more than one or two pieces of music, even though they expressed that it was very beautiful and nice to hear. In a study of active music therapy intervention by (Fallek et al., 2020), 40% declined participation, and common reasons were feeling too tired or awaiting discharge from the hospital. Therefore, it seems important to remain very alert to the patient’s capacity in the situation.

In our study, to musicians and patients alike, live music established a special connection if the piece of music was known by the patient and if he or she could relate to it. The music would bring out memories that provided comfort and allowed the patient to think about something else. With reference to the music, a bond would occasionally arise between the patient and the musicians; for the patient, this would create a sense familiarity and comfort. In the white paper by (Jespersen et al., 2022), this was described as the familiarity in music, which seems to be very important for our appreciation of music. The authors argued that people are consistently found to experience familiar music as more pleasurable than unfamiliar music (Vuust & Kringelbach, 2010). In line herewith, Gebauer and Vuust (2014) described episodic memories as one of the seven distinct mechanisms of music that are capable of unleashing strong emotions and pleasure (Vuust & Kringelbach, 2010). On the other hand, Gebauer et al. (2012) argued that the unfamiliar and the familiar aspects of music need to be balanced. In relation to the ambition of humanizing the ICU, the familiarity of music might be particularly useful because it brings forward notions of the outside world, specifically memories of home and family, into the ICU.

In our study, the patients were highly fascinated by the musicians, how skilled they were with their instrument and how good it sounded. This created an intimacy and closeness that made the experience very special. In a Dutch project titled Meaningful Moments in health Care, a patient and a musician had a very special eye contact while the musician improvised a music piece for the patient, and both the musician and the patient described the moment as very intimate and rather emotional; it was very beautiful and touched them both deeply (Heniks & Smilde, 2017). Even though we did not interview the musicians, we saw in the observations that a sense of intimacy filled the rooms along with the music. We will argue that this intimacy, closeness and beautiful touch are exactly what the live component of the music performance brings to the experience, which is so important for humanizing ICU. Humanizing ICU is a trend in ICU nursing with has been debated for some years; how to humanize the intensive care units and whether humanization is necessary at all? In a recent review Kvande et al. argues that humanized care involves seeing the patient and relative as fellow human beings, providing attention to their needs and their situation (Kvande et al., 2022). We will argue that through live music the patient (and relative) is seen and touched and a steep towards humanization in the ICU is started.

Music interventions in the ICU and elsewhere have received scientific interest. However, evidence remains spare. In regard to live music in the ICU, we suggest that the arts of high-quality live music interventions may have great potential for supporting health and well-being and bringing a humanizing resource into the ICU. We must acknowledge the potential and conduct further explorative and implementation studies to move ICU closer to the goal of humanizing ICU (Heras La Calle et al., 2017).

Strength and limitation

The qualitative approach using both observations and interviews as data collection methods proved to be excellent for capturing the experience of the live music intervention between the musician and the non-sedated patient in the ICU. The data presented are comprehensive, and the combination of interviews and observations includes perspectives from both patients and musicians, providing insights into their interaction. A challenge in the study was the difficult task of interviewing ICU patients. Because of their acute and critical condition, they were often unable to provide long narrations. However, the approach provided a unique insight into the lived experiences in the ICU when interviews were performed during admission right after the intervention rather than afterwards in the ward. Furthermore, being a research team in your own field presents some challenges as pre-understandings need to be considered and the researcher needs to be constantly aware of the need to bridle his or her pre-understandings or use them to wonder. Conversely, this gave access to the field and afforded us with the possibility of conducting participant observations that supplemented the interviews and enriched the data collected. Even though we collected data four years ago, we will argue that the findings are illustrative and representative as the intervention has been performed in the same way every week since the start of the project. We had a special emphasis on patients in the ICU being a vulnerable patient group and therefore, had a nurse caring for the patient to select the patients who were asked for participation, we experienced a patient being too tired to participate. Therefore, only two pieces were played, and the patient still described the experience to be wonderful. With that in mind a special emphasis always needs to be taken on the patient’s current condition.

Implications for practice

The growing number of lightly or non-sedated patients in the ICU means that providing comfort and ensuring compliance in nursing care are more challenging than ever. Findings from this study showed that the ICU patients’ experiences ranged from positive and meaningful moments to a noisy and stressful environment, underpinning that efforts should be made to support care interventions that promote comfort, calmness and comprehension. It is, however, also important to acknowledge that apart from suffering from critical illness, ICU patients are characterized by physical weaknesses and fatigue that complicate participation in interventions and that not all noise can be avoided. Based on our findings, we recommend introducing a systematic music strategy in the ICU consisting of the following nursing interventions to reduce hecticness in the ICU: (1) systematic assessment of music interventions in cooperation with music experts; (2) using different music interventions when possible; and (3) securing time, continuity, empathy and patience in nursing care. Furthermore, technological advances in access to music may afford patients the possibility to choose between different music interventions during their ICU stay, an opportunity that should be investigated further.

Conclusion and future perspectives

Bringing live music into the ICU where students from the Royal Academy of Music offered classical and contemporary music to awake ICU patients is both feasible and acceptable according to the patient-reported experience.

Our findings showed that live music provided a break from everyday life in the ICU. The experience was described as nice, human and homely, a moment of calm, providing relaxation and leaving positive impressions. The live nature of the music intervention was described as incredible and a bodily beautiful experience, giving everyone in the room gooseflesh. Also, the experience was so touching for musicians and patients alike that they occasionally cried a little because the experience was so beautiful and human. To both the musicians and the patients, music could bring forward a special connection when the patients knew and could relate to the repertoire of music played.

Evidence of live music interventions in the ICU remains sparse. However, as this paper shows, live music may harbour a great potential for supporting health and well-being and bringing a humanizing resource into the ICU. Therefore, future study is warranted of patient experiences and physical outcomes of live music in the ICU. Hopefully, this may bring ICU closer to the overall goal of being a humanizing environment.

Author contributions

All authors have substantially contributed to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work. All authors have drafted or revised the paper critically for important intellectual content. All authors have given final approval of the version to be published. All authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments

We would like to thank all the participating intensive care units at Aarhus University Hospital for their support in the study. Especially, we express our gratitude to CCRN Ulla Otte, for her fostering the idea of live music concerts in the ICU played by music students from The Royal Academy of Music and for CCRN Anne Rönningen Lund Andersen for collecting data and guiding the musicians. Furthermore, we would like to thank all the musical students who created meaningful musical moments in the ICU and, of course, a special thanks to the patients and relatives who participated in the study.

Disclosure statement

No potential conflict of interest was reported by the authors.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/17482631.2024.2322755

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes on contributors

Pia Dreyer

Pia Dreyer (RN, MScN, PhD) is a professor within clinical ICU nursing and home mechanical ventilation. She is employed both at Aarhus University, Department of Public Health, Section of Nursing and Health Care, the Department of Intensive care at Aarhus University Hospital. She has in-depth knowledge of the experiences of mechanically ventilated patients and is working to humanize the ICU environment together with her research group. Also, she is acknowledged within the scientific traditions of phenomenology and hermeneutics and has developed a Ricoeur-inspired interpretation method.

Linette Thorn

Linette Thorn (RN, CCRN, MScN,) has worked with ICU patients since the beginning of her nursing career. She has been preoccupied with understanding the experiences of ICU patients and working to humanize the ICU environment, particularly with nursing care and music interventions. In private music is also a major part of her life, as she is both a singer and plays the piano. At the moment she is a specialist nurse within intensive care nursing at Aarhus University Hospital in Denmark.

Trine Højfeldt Lund

Trine Højfeldt Lund (RN, CCRN, head nurse) is a head nurse at Department of Intensive Care, Aarhus University Hospital, in Aarhus. She is leading nurses, nursing students and Critical Care Nursing Trainees. For several years she has ample experience in leading highly intensive care nursing practice and critical care nurses. Furthermore, she has great interest in research with the focus on clinical nursing practice.

Margrethe Langer Bro

Margrethe Langer Bro (Pianist, PhD, Associate Professor) is an Associate Professor at The Royal Academy of Music, Aarhus/Aalborg and at The Danish National Academy of Music Odense/Esbjerg, Denmark. She graduated as a solo pianist from The Royal Academy of Music in 1998 and holds a PhD degree from 2019. She has been working as a professional musician as well as a lecturer, supervisor and coach for music students, professional ensembles and health care professionals within the area of artistic citizenship since 2005. Her research interests include exploring patient‐centred music interventions in the healthcare environment.